M------- P---- Ph.D. Clinical Psychologist / Neuropsychologist NEUROPSYCHOLOGICAL EVALUATION Name: Date of Birth: Date of Evaluation: 05-28-2015 Tests Administered: Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV)-selected subtests; Boston Naming Test; Wechsler Memory Scale-Fourth Edition (WMS-IV)-selected subtests; California Verbal Learning Test-II (CVLT-II); Wisconsin Card Sorting Task-64 Card Version (WCST-64); Delis-Kaplan Executive Function System (D-KEFS)-selected subtests Referral and Relevant History: B------ M------ was referred by her neurologist for neuropsychological evaluation with emphasis on memory and executive functioning. She reported experiencing increased stress at work. She is a. She took a leave of absence from December 2013 to October 2014. She reported having a history of depressive (including mild post-partum depression) and anxious (including Obsessive-Compulsive Disorder symptoms) breakdowns, and what she described as flat affect. She has psychotherapy and medication consultations at Riverside Community Care. She has been prescribed Prozac and Wellbutrin. Her medical history includes her being treated for a thyroid condition, high blood pressure and fibromyalgia. She reported being told that her recent brain MRI was negative (nothing wrong). Mrs. M described having had an abusive and dysfunctional childhood and family life. [[[Family history and family mental illness background here]]]]
Test Results and Observations: Cognitive functioning was evaluated through two subtests from the Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV). Mrs. was given one Verbal Comprehension subtest (Vocabulary) and one Perceptual Reasoning subtest (Matrix Reasoning). On the Verbal Comprehension subtest, she scored higher within the average range for knowledge of word meanings and verbal concept formation (Vocabulary). On the Perceptual Reasoning subtest, she scored within the superior range for visual-spatial reasoning abilities including classification, part-whole relationships and simultaneous processing (Matrix Reasoning). For subtest scores displayed below, 10 is the average score within a range of average scores from 8 to 12. WAIS-IV Verbal Comprehensio n Perceptual Reasoning Vocabulary 12 Matrix Reasoning 15 The Boston Naming Test provided an evaluation of Mrs. s word finding (confrontational naming) skills. She scored higher within the average range for her age (.78 of a standard deviation above the mean) with 58 of the 60 line drawings of objects correctly identified. Subtests from the Wechsler Memory Scale-IV (WMS-IV) were used to evaluate Mrs. M s verbal and visual memory functioning. For the WMS-IV subtest scores, 10 is the average score within a range of average scores from 8 to 12. WMS-IV subtest scores are displayed below. Verbal Memory Logical Memory I Logical Memory II WMS IV Visual Memory 14 Visual Reproduction I 15 Visual Reproduction II 14 9 Verbal memory was assessed through recall of details from two conceptually organized and semantically related narratives. Mrs. scored within the superior range for immediate recall of the two narratives (Logical Memory I), and also
within the superior range for delayed recall of the two narratives (Logical Memory II). Visual memory was assessed through recall (by drawing) of details from five increasingly more complex abstract designs. Mrs. scored within the superior range for immediate recall of design details (Visual Reproduction I), and within the average range for delayed recall of design details (Visual Reproduction II). Verbal memory skills were further evaluated through the California Verbal Learning Test-II (CVLT-II). The CVLT-II is a repeated trials verbal learning and memory task. A sixteen-word list (List A) is presented without organization though the words fit into four semantic categories of four words each including furniture, vegetables, ways of traveling and animals. List A was repeated five times and Mrs. recalled as many of the sixteen words as she could after each repetition. Then a second list of sixteen words (List B) was presented with one recall trial as an interference distracter. Then for short-delay trials, List A was recalled first without organization (free recalls) and then with attention to the semantic categories (cued recalls), as she was asked to recall the words from the list that were furniture, then vegetables, then ways of traveling and then animals. The short-delay trials were repeated twenty minutes later by long-delay trials. After long-delay trials, she completed a recognition and discrimination test of forty-eight words. Sixteen of the words were from List A (to be recognized), and thirty-two of them were non-list A words (to be discriminated) including the List B words, words fitting the semantic categories but not from List A, and unrelated words. For the List A Total Trials 1-5, 50 (T-scores) is the average score within a range of average scores from approximately 40 to 60. For the remaining scores, 0.0 (z-scores) is the average score within a range of average scores from approximately -1.0 to 1.0. CVLT-II scores are displayed below. CVLT-II List A Total Trials 1-5 List A Trial 1 Free List A Trial 2 Free List A Trial 3 Free List A Trial 4 Free List A Trial 5 Free List B Free 66 0.0 0.5-0.5
List A Short- Delay Free List A Short- Delay Cued List A Long- Delay Free List A Long- Delay Cued Recognition Errors of Omission Discrimination Errors of Commission 0.5 0.5 CVLT-II scores indicated Mrs. s superior range word list learning and memory functioning (List A Total Trials 1-5 ). She scored within the average range for number of words recalled after the first two of the five learning trials (List A Trial 1 Free, List A Trial 2 Free ), and within the superior range for number of words recalled after the last three of the five learning trials (List A Trial 3 Free, List A Trial 4 Free, List A Trial 5 Free ). She scored within the average range for number of words recalled after the distracter list (List B Free ). After short-delay, she scored within the superior range for the free (List A Short-Delay Free ) and cued (List A Short-Delay Cued ) recalls. After long-delay, she also scored within the superior range for the free (List A Long-Delay Free ) and cued (List A Long-Delay Cued ) recalls. For the recognition / discrimination test, she scored within the average range (sixteen of the sixteen words recognized) for recognizing the List A words (Recognition Errors of Omission) and within the average range (one of the thirty-two words not discriminated) for discriminating the non-list A words (Discrimination Errors of Commission). Auditory working memory was assessed through one subtest from WAIS-IV that assessed immediate recall of spans of numbers as presented demanding attention, encoding and auditory processing; in reverse order demanding mental manipulation, transformation of information and visuospatial imaging; and in sequential order (lowest to highest) demanding mental manipulation and working memory. Mrs. scored higher within the average range for auditory working memory on Digit Span (from WAIS-IV). The Auditory Working Memory subtest score is displayed below. For this subtest score, 10 is the average score within a range of average scores from 8 to 12.
Auditory Working Memory Digit Span (from WAIS- IV) 12 The Wisconsin Card Sorting Test-64 Card Version (WCST-64) is a test of mental response set shifting in accord with shifting task demands. The task was to match cards based on categories including color of (red, yellow, green or blue), form of (i.e., circles, crosses, stars and triangles) and number of (from one to four) objects on the card. The correct category shifted from color to form to number, so Mrs. needed to pay close attention to the shifting correct-incorrect feedback to direct her responses through the category shifts. The only feedback she received was whether matches she made were correct or incorrect. Sometimes the cards match on more than one category (e.g., cards match on both color and form), but only one category is correct. She completed five WCST-64 categories for a very efficient performance of mental response set shifting. The Delis-Kaplan Executive Function System (D-KEFS) provided an assessment of Mrs. M s executive functioning. For the subtest scores, 10 is the average score within a range of average scores from 8 to 12. D-KEFS subtest scores are displayed on the next page. D-KEFS - Color-Word Interference Tests Color Naming 12 Word Reading 8 Inhibition 8 Inhibition 9 Switching D-KEFS - Verbal Fluency Tests Letter Fluency 13 Category 10 Fluency The Color-Word Interference Tests included four subtests that emphasized quick verbal responses and resistance to visual distractions. The four subtests were Color Naming (naming word-size patches of the colors green, blue and red ), Word Reading (reading names of the colors green, blue and red printed in black ink), Inhibition (naming the color
of the ink in which the word is printed - green, blue or red - rather than the color name: e.g., for the word green printed in red ink, saying red ) and Inhibition / Switching (like the Inhibition test except that if the word is in a box, one reads the word and does not name the color of the ink). Mrs. M scored higher within the average range for quickly naming colors (Color Naming) and lower within the average range for quickly reading color names (Word Reading). She scored lower within the average range for the visual interference / inhibition task (Inhibition), and within the average range for the visual interference / inhibition and switching task (Inhibition / Switching). The Verbal Fluency Tests included three subtests that emphasized Mrs. M making many quick verbal responses within a one-minute time limit under different conditions. For Letter Fluency, she needed to list quickly as many common words as she could beginning with F for one minute, then with A for one minute and then with S for one minute. For Category Fluency, she needed to list quickly as many words as she could within semantic categories such as types of animals and boys names beginning with any letter. For Category Switching, she needed to list quickly as many words as she could within the semantic categories of types of fruits alternated with types of furniture beginning with any letter. Mrs. M scored within the high average range for phonemic (organizing words by phonics or sounds of letters) processing skills (Letter Fluency), and within the average range for semantic (organizing words by category and meaning) processing skills (Category Fluency). Conclusions and Recommendations: Neuropsychological evaluation data indicated that Mrs. M had average to superior range cognition, word finding, verbal and visual-spatial memory, auditory working memory and executive functioning. There were no scores below lower within the average range. There is no evidence from this data of Mrs. M having cognitive impairment: more specifically no evidence of memory or executive functioning impairment. Mrs. M s relatively weaker scores were for the delayed recall of abstract visual designs (Visual Reproductions II) and for the inhibition executive functioning task (Inhibition subtest on the Color Word Interference Tests). These were highly demanding tasks relative to the other tasks of the evaluation. The delayed recalls of abstract visual designs compared to any immediate recalls and verbal recalls demands greater information processing because abstract visual material is less familiar than verbal material. Information processing can be and often is limited by depression and anxiety. The speeded inhibition task compared to the untimed mental set shifting and speeded verbal tasks demands greater immediate sustained concentration. Immediate sustained concentration can be limited by depression and anxiety. These are only lower scores compared to her other higher scores. They are not below average scores. They indicated the possible effects of depression and anxiety as limitations on her performances. This may relate to her everyday experiences at work. The stresses of an abusive (as perceived by her) work situation could account for her performance decrements. Her reported history of family abuse and dysfunction supports the likelihood
that stress adversely affects her now. Mrs. M needs to continue with her medication consultations and individual psychotherapy. This data does not support any significant cognitive functioning deficit including no deficits of memory or executive functioning. DSM-V Diagnostic Impressions by History: 296.32 Major Depression, Recurrent, Moderate 300.02 Generalized Anxiety Disorder. M, Ph.D. Clinical Psychologist / Neuropsychologist